197606562-7-20-2023-31-AS-APAA-CTWNSU-20230720104343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606562
Report Date: 07/20/2023
Date Signed: 07/20/2023 10:44:27 AM

Document Has Been Signed on 07/20/2023 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROYALTY GUEST HOME, INC.		FACILITY NUMBER:	197606562
ADMINISTRATOR:	ELENA ANGUSTIA		FACILITY TYPE:	740
ADDRESS:	20609 BRYANT STREET		TELEPHONE:	(818) 727-1741
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 2	DATE:	07/20/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Elena Angustia, Administrator		TIME COMPLETED:	11:00 AM

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On 07/20/2023, Licensing Program Analyst (LPA) Angela Panushkina met with Elena Angustia, Administrator, also representing Licensee, for a Case Management visit to issue a Civil Penalty per Health and Safety (H&S) Code §1569.49.

On December 7, 2017, the Department received a complaint that alleged staff neglected a resident resulting in hospitalization. The resident was reportedly hospitalized with septic shock and unstageable pressure injuries on the coccyx, right thigh and hand.

The Department conducted an investigation which revealed on December 6, 2017, Resident 1 (R1) was transported from this facility to the hospital due to being found unresponsive and having difficulty breathing. Hospital medical records reflect R1 was unconscious upon arrival to the hospital. Upon admission, R1 was diagnosed with severe septic shock with acute organ dysfunction, acute renal failure, and urinary tract infection. Medical records also indicate R1 had multiple pressure injuries including a stage 4 pressure injury to the right hand, and unstageable pressure injuries on the sacrum, right lateral malleolus, right lower leg, and left heel. Interviews revealed R1 was not receiving home health nor hospice services while residing in this facility. R1 ultimately expired in the hospital on December 7, 2017.

According to interviews, the Licensee/Administrator is the niece of R1. R1 moved into this facility approximately six and a half years ago, and around May 2017, R1’s health rapidly declined. The Licensee/Administrator first observed a pressure injury on R1 around the middle of November 2017. Though the Licensee/Administrator reportedly attempted to care for R1’s pressure injury, the injury worsened faster than anticipated. The Licensee/Administrator admitted R1’s pressure injuries progressed beyond stage 1-2

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
	VISIT DATE: 07/20/2023

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to unstageable under facility staff’s care and supervision. R1’s pressure injuries were observed on R1’s buttock, foot and side of the hand. The Licensee/Administrator stated once the pressure injuries were observed on R1, R1 was taken to R1’s regularly scheduled doctor visits, and the Licensee/Administrator requested additional guidance from the doctor on how to increase the level of care provided to R1. The Licensee/Administrator admitted only completing training to become a physician in the Philippines.

On April 17, 2018, the allegation that facility staff failed to provide adequate care and supervision resulting in hospitalization was Substantiated. Interviews revealed the licensee had knowledge of the pressure injuries from the middle of November 2017, but retained R1 in the facility, and did not seek home health or hospice care services, which ultimately resulted in serious bodily injuries. The licensee was cited per Title 22 California Code of Regulations (22 CCR) § 87615(a)(1) Prohibited Health Conditions which in part states “Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure sores (dermal ulcers)”; 22 CCR § 87405(d)(1) Administrator Qualifications and Duties which in part states the Administrator shall have the “knowledge of the requirements for providing care and supervision appropriate to the residents”; and 22 CCR § 87466 Observation of the Resident which in part states “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.” An immediate civil penalty of $500 was also assessed during the visit.

This requirement was not met as evidenced by:

Based on interviews and record review, the licensee was aware of R1’s pressure injuries yet retained R1 with the prohibited health condition and did not seek timely medical attention for R1.

On August 01, 2018, the licensee was informed during a Non-Compliance Conference that an additional civil penalty might be assessed for a violation resulting in serious bodily injury to a resident in care. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
	VISIT DATE: 07/20/2023

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injury. Per Welfare and Institutions Code (W.I.C.) §15610.67: "Serious bodily injury" means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, 07/20/2023, the Department will be issuing a civil penalty per H&S Code §1569.49 for $10,000. However, since an immediate civil penalty of $500 was issued on April 17, 2018, the amount of the civil penalty issued today will be $9,500.

Exit interview conducted. Appeal rights provided. A Copy of the report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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